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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700361
Report Date: 06/17/2022
Date Signed: 06/17/2022 11:25:47 AM


Document Has Been Signed on 06/17/2022 11:25 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833



FACILITY NAME:STACIE'S CHALET STOCKTONFACILITY NUMBER:
392700361
ADMINISTRATOR:ANURADHA SAINIFACILITY TYPE:
740
ADDRESS:517 E FULTON STTELEPHONE:
(209) 910-5910
CITY:STOCKTONSTATE: CAZIP CODE:
95204
CAPACITY:0CENSUS: 0DATE:
06/17/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
11:13 AM
MET WITH:Report mailed to previous licenseeTIME COMPLETED:
11:45 AM
NARRATIVE
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On 6-17-22 at 11:13am, Licensing Program Analyst (LPA) Michael Bilger conducted a case management visit regarding attempts to locate facility file documentation for a previous resident. During visits on 1-24-22 and 5-24-22, LPA requested chart record for resident1 (R1) who ended residency on 1-20-21. Staff at facility location, now operated by a different licensee attempted to locate chart record but was unsuccessful. Additional email on 6-2-22 requesting the status of chart record was also unsuccessful. A subpoena for chart records was submitted on 2-11-22 in attempts for licensee to provide chart record to licensing department as requested. This attempt was also unsuccessful. Based on attempts to receive requesting facility documentation, it is determined that licensee has not provided material to licensing department upon request, nor does licensee retain the facility file documentation as requested by licensing department.

Deficiencies are cited as result under Title 22, Division 6, Chapter 8. A copy of this report will be sent certified to licensee with a request for return signature. Appeal Rights Provided

SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Michael BilgerTELEPHONE: 916-862-4722
LICENSING EVALUATOR SIGNATURE:
DATE: 06/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/17/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2


Document Has Been Signed on 06/17/2022 11:25 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833


FACILITY NAME: STACIE'S CHALET STOCKTON
FACILITY NUMBER: 392700361

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/17/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/20/2022
Section Cited

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Resident Records (d) All resident records shall be available to the licensing agency to inspect, audit, and copy upon demand during normal business hours… This requirement is not met as evidenced by:
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Based on interview and observation, licensee did not provide facility file documentation for R1 upon request by licensing department. This poses a potential health, safety, and resident rights risk to residents in care.
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Type B
06/20/2022
Section Cited

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Resident Records (e) Original records or photographic reproductions shall be retained for a minimum of three (3) years following termination of service to the resident. This requirement is not met as evidenced by: Based on interview and observation, licensee did not maintain original or photographic reproductions of facility file for R1 for three years. R1 terminated residency on 1-20-21. This poses a potential health, safety, and resident rights risk to residents in care.
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 Based on interview and observation, licensee did not maintain original or photographic reproductions of facility file for R1 for three years. R1 terminated residency on 1-20-21. This poses a potential health, safety, and resident rights risk to residents in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Michael BilgerTELEPHONE: 916-862-4722
LICENSING EVALUATOR SIGNATURE:
DATE: 06/17/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/17/2022
LIC809 (FAS) - (06/04)
Page: 2 of 2